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Therapeutic Communities Today and Tomorrow: Meeting the Challenge

Therapeutic Communities Today and Tomorrow: Meeting the Challenge. George De Leon Senior Scientist@ NDRI: Clinical Professor of Psychiatry; NYU School of Medicine Remarks Presented to 14 th EFTC Conference Prague, Czechia; Sept. 2013. EVOLUTION AND STATUS.

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Therapeutic Communities Today and Tomorrow: Meeting the Challenge

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  1. Therapeutic CommunitiesToday and Tomorrow:Meeting the Challenge George De Leon Senior Scientist@ NDRI: Clinical Professor of Psychiatry; NYU School of Medicine Remarks Presented to 14th EFTC Conference Prague, Czechia; Sept. 2013

  2. EVOLUTION AND STATUS • The evolution of the contemporary TC for addictions over the past 45 years may be characterized as a movement from the marginal to the mainstream of substance abuse treatment and human services. • Currently TCs serve a wide diversity of clients and problems; they have reshaped staffing composition, reduced the planned duration of residential treatment, reset its treatment goals and to a considerable extent, modified the approach itself.

  3. Evolution (Con’t) These changes are expected and consistent with the TC's own teaching, which stresses that theonly certainty in life is change itself. • However, as it assumes the characteristics of a mainstream public health entity, the future of the TC approach itself contains a profound and paradoxical threat—the loss of its unique self-help identity which has defined its success.

  4. THE CHALLENGE To convert threat into an opportunity to advance its approach, the TC must address several issues several of which are briefly highlighted: • Funding and Planned duration of Treatment • Evidence and Effectiveness • Clinical Practice and Fidelity of TC Treatment;

  5. Funding . Issue: Funding pressures have dramatically reduced the planned duration of treatment, This policy contradicts the science documenting the relationship between retention and outcomes in community and correctional TC studies. • Thus, for the large majority of TCs that depend upon public funding, planned duration of treatment has been reduced often below the threshold of time needed to yield positive outcomes. • This adjustment to funding pressures potentially undermines the viability of the TC as a cost effective modality in the health care system.

  6. Funding An informed funding policy must be guided by the current state of clinical and research knowledge which underscores the paradigm of client- treatment matching.

  7. Funding Matching: What We Know • Client Severity-Treatment Intensity paradigm • Cost of Mismatching: Overtreatment, Under treatment and Sufficient Treatment • Self-Matching: Clients elect the intensity of treatment for various reasons (with exception of legal mandate). • For clients with severe disorder in terms of substance abuse, social deviancy and psychological profiles, longer term residential TC is the treatment of choice.

  8. Funding-Planned Duration The challenge to TCs is to modify programming based on the facts of matching. Three examples: • Refine treatment-matching options for different levels of severity • Planned Duration and Treatment. Longer and shorter planned durations are offered in residential and non-residential settings. Setting (intensity) depends upon client (severity) profile and stage of recovery.

  9. Funding-Planned Duration • Adjustment of clinical goals within the constraints of planned duration. • Shorter term programs cannot achieve the recovery goals of longer term treatment. If TCs reduce their planned duration to serve clients with severe disorderthey must establish goals that can be realistically achieved in a shorter period of time. • These goals center on motivating and preparing clients to continue in their recovery process beyond their briefer duration in residential treatment.

  10. Funding-Planned Duration • Deploy Long term protocols of combined residential and non residential components. “Reconstitute time in program”. • Appropriate “dosage” (threshold) of treatment can be achieved by shortening the duration of residential treatment and extending the duration of nonresidential treatment and aftercare. • Implement recovery oriented systems. Link providers, and settings in a systems which promote recovery, rather than manage disease.

  11. The Issue of Evidence • In the universal call for evidenced-based treatments some critics have concluded that the TC is not an evidenced based treatment. • What is the Evidence? Direct (based on TC outcome research) and indirect (based on non-TC research).

  12. Direct Evidence • The “weight of evidence” from multiple sources of outcome research” documents that the TC is an “evidence based” approach and supports the hypothesis that the TC is an effective and cost- effective treatment for certain subgroups of substance abusers • Multi-program, multi-modality field effectiveness Studies ( e.g., DARP, TOPS, NTIES, DATOS,) • Single program case studies, (e.g., Daytop, Eagleville, Gateway, Phoenix House) • Control and Meta analytic studies • Cost benefit studies

  13. Indirect Evidence • Evidence-based learning principles are contained in TCs: Examples: • Social role training: ( Peer roles in the organizational structure) • Vicarious learning: ( identification with others) • Behavior modification: (Consequential Learning; privilege/sanctions) • Efficacy training: (trial/error learning) • These principles are naturalistically mediated; embedded in Community as Method.

  14. Indirect Evidence • Evidence- based Practices and Elements • Peer mentoring; Peer feedback, tutoring; • CBT, RPT,TC concepts: in Peer/staff Seminars; • Motivational enhancement: peer support and group process; (focus on problem identification and desire to change). • Goal Attainment: Program Stages and Phases • Therapeutic Alliance: Community vs Therapist

  15. Conclusion: The TC is an Evidenced Based Approach • Distinction between evidence based practices and programs. TCs are evidenced based programs. • The evidence is both direct (outcome studies) and indirect(Evidenced- based elements and practices, are embedded within Community as Method). • Community as Method is the Primary Treatment. Other evidenced informed strategies are incorporated to enhance, not substitute for, community as method.

  16. TCs OR NOT TCs: Classification • A classification of TC programs is essential to assess their appropriateness and effectiveness for different populations. A suggested 3 category classification derived in part from earlier field survey studies is TC- Standard, TC- Modified and TC- Oriented. • These broad categories are based upon the extent to which a program is guided by the TC theory ( i.e., perspective on the disorder, recovery and right living), adheres to the method (i.e., Communty as Method) and retains essential components of the program model (e.g., community meetings, seminars, peer groups, resident organizational structure, etc.). • Standard and Modified programs may employ other evidence based strategies e.g., cognitive behavioral therapy (CBT), motivational enhancement therapy (MET, Seeking Safety, Family therapy etc.). These strategies are incorporated as enhancements of, not substitutes for, community as method, the primary treatment approach.

  17. Varieties of TCs • Standard TC Programs. These are guided by the TC perspective, retain essential components of the program model and utilize community as method as the primary approach. They are mainly housed in residential settings, with longer planned durations of treatments, serving the more severe substance abusers. Primarily client driven • Modified TC Programs: These are guided by the TC perspective, incorporate essential components of the model, but adapt community as method for special populations ( e.g. Co- Occurring Disorders; criminal justice substance abusers, juveniles) and settings (hospitals, shelters, prisons). Key adaptations are more staff directed, greater emphasis on individual differences, moderated intensity of group process, and a more flexible program structure. Additionally these programs incorporate strategies and services which have proven useful in addressing particular problems and special populations including pharmacotherapy ( e.g., methadone, buprenorphine, psychotropic medications) as well as varieties of counseling and family therapy). Client and staff driven • Oriented TC Programs: These are not guided by the TC perspective and do not adhere to community as method. Typically, these serve less severe clients in short term residential or day treatment settings and are eclectic in their approach. They select elements of the TC (e.g. community meetings, peer support group etc) but mainly utilize services and practices that are not specific to the TC. Primarily staff driven

  18. Clinical Practice • TCs understandably have pursued financial solvency by expanding to serve a wide variety of populations e.g., mental health, homeless, corrections, juvenile justice and child care. • Contracts have obligated TCs to meet regulations of community, state and federal agencies and often to incorporate practices based upon different professional views of treatment. • As TCs modify they increasingly incorporate non -TC practices into their programs e.g. CBT, MET, DBT, Contingency Contracting, pharmacotherapy, varieties of Family therapy.

  19. Clinical Practice • The expansion outward of the TC has been at the expense of inward refinement of the approach itself. • Some effects of these changes may be described in terms of dilution of the TC approach and erosion of treatment fidelity. • TCs can refine community as method as the primary treatment ingredient through a focus on Fidelity. .

  20. The Fidelity of Treament • TC effectiveness and fidelity of treatment are closely related. High fidelity treatment produce better outcomes. • The key strategies needed to assure high fidelity TCs are training and fidelity assessment. • Training to fidelity involves three critical elements;1) a uniform definition of community as method 2) a teaching curriculum and 3) an appropriate training model.

  21. A Uniform Definition • The TC can be distinguished from other approaches and other communities in its use of community as a primary method of treatment. • Community as method is defined as the purposive use of community to teach individuals to use the community to change themselves. • Teaching curricula: Teaching materials and manuals based upon a uniform definition of the TC must focus on the relationship between theory and practice: This can be summarized in 3 questions: What, how and why we do what we do in therapeutic communities?

  22. “TC Centers of Excellence” • Experience indicates that training for workers in TCs requires combinations of didactic teaching of theory and practice as well experiential learning as participants in TCs. While conventional training approaches are useful, the most appropriate training model to be considered is the TC Teaching Program ie., The TC Center of Excellence • Selected high fidelity TC programs serve as the primary training sites for cadres of staff who rotate through these programs for several months. Direct daily experience in the roles and activities of the TC that are implemented correctly produces the most efficacious training effects. • Analogous training models are found in conventional graduate and post doctoral health settings. These are based on the well grounded assumption that staff should learn their specialty in the “best teaching hospitals.”

  23. THE TC TOMORROW THE RECOVERY MOVEMENT: WHAT WE HAVE LEARNED FROM THERAPEUTIC COMMUNITIES

  24. PAST AS PROLOGUE “ Arguably, the therapeutic community for addictions (TC) is one of the first formal treatment approaches that is explicitly recovery oriented. Surely, AA and similar mutual self help approaches facilitate recovery but these represent themselves as support, not treatment. Pharmacological approaches, notably, methadone maintenance, have as their treatment goal the reduction or elimination of illicit opiate use; and evidenced based behavioral approaches, such as cognitive behavioral therapy (CBT), contingency contracting, motivational enhancement (MET) focus upon reduction in targeted drug use. “

  25. PAST AS PROLOGUE (Con’t) “In the TC perspective, however, the primary goal of treatment is recovery which is broadly defined as changes in lifestyle and identity. These changes involve abstinence from all non prescribed drug use, elimination of social deviance and development of pro social behaviors and values “ • De Leon: (2010) The Therapeutic Community: A Recovery Oriented Treatment Pathway and The Emergence of a Recovery Oriented Integrated System. In ( R. Yates and M.Mallloch Editors) Tackling Addiction; Pathways to Recovery (pp.70-83) London, Jessica Kingsley Publishers

  26. THE TC and RECOVERY: SUMMARY • A Perspective (and Definition) of Recovery. • A Research literature Documenting the Fact of Recovery. • A Recovery Stage Framework illustrating the Recovery Process. • A Model for a Recovery Oriented System (ROIS) of Treatment and Aftercare.

  27. Recovery SAMHSA A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Through the Recovery Support Strategic Initiative, SAMHSA also has delineated four major dimensions that support a life in recovery: • Health: Overcoming or managing one's disease(s) as well as living in a physically and emotionally healthy way. • Home: A stable and safe place to live. • Purpose: Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society. • Community Relationship.

  28. Beyond Treatment: A Recovery Oriented Integrated System • A distinction between managing disease and promoting recovery is the basis for system change. • The current system of treatment and services must be integrated to sustain the individual in the recovery process. • The TC recovery perspective and program stage format, particularly, the re-entry stages, guide the development of a recovery oriented integrated system.

  29. A RECOVERY ORIENTED INTEGRATED SYSTEM (ROIS) • ROIS is a paradigm of a systems approach It consists of interrelated treatment interventions, surveillance, supportive, and social services provided in a variety of settings, which is guided by a common perspective on the disorder and recovery. • The integrative ingredient of the systemis an overarching framework of recovery.

  30. KEY ASSUMPTIONS OF ROIS • In a ROIS, settings and modalities may change, but their purpose remains the same, to move the individual to the next stage in the process of recovery. • Treatment services, social services and surveillance differ in their contribution to the recovery process.

  31. KEY ASSUMPTIONS OF ROIS (Cont’d) • The optimal utilization of treatment and social services in institutions, halfway houses, day treatment or outpatient settings depends upon the client’s stage of recovery. • The optimal utilization of the system itself is maximized by continued affiliation with positive peer associates • Thus, continuity of perspective (Recovery), and of peer relationships (Community) are sustaining elements of an integrated system.

  32. A RECOVERY ORIENTED INTEGRATED SYSTEM (ROIS) (cont’d.) • Key components of ROIS are: • Recovery Stage Framework • System-wide vernacular • Uniform assessment protocol • Coordinated procedures for referral and placement.

  33. Suggested Readings De Leon, G. (2011).The Recovery Movement: What We Have Learned From Therapeutic Communities for Addictions: Plenary Address to  Recovery Academy 2nd Annual Conference Edinburgh, Scotland, Sept. 27, 2011 White W.I..(2010). Interview with G. De Leon, and D. Deitch. Recovery Management and the Future of the Therapeutic Community; in Counselor: Magazine for Addiction Professionals, Oct. 2010, Vol.11, No.5 De Leon: (2010) The Therapeutic Community: A Recovery Oriented Treatment Pathway and The Emergence of a Recovery Oriented Integrated System. In ( R. Yates and M. Malloch Editors) Tackling Addiction; Pathways to Recovery (pp.70-83) London, Jessica Kingsley Publishers  De Leon, G.(2010) Is the Therapeutic Community an Evidenced Based Treatment? What the Evidence Says. International Journal of Therapeutic Communities 31, 2, summer 104-128  De Leon, G. (2007). Therapeutic Communities in correctional settings: Toward a recovery oriented integrated system. Offender Substance Abuse Report, V11(4). De Leon, G. (1996). Integrative recovery: A stage paradigm. Substance Abuse, 17 (1), 51-63; . De Leon, G. (1995). Residential therapeutic communities in the mainstream: Diversity and issues. Journal of Psychoactive Drugs, 27 (1), Jan-Mar, 3-15

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